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CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachca.gov 1 (949) 644-3200
NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has be nqJ ed i9, our name listi ourself as ��� de/r 0
the property improvements specified atY l� 1 e� ,mine /moi (dP r' V �V/
We are providing you with an Owner -Builder Acknowledgment and Informs ion Verificati n Form to
make you aware of your responsibilities and possible risk you may incur by having this permit issued in
your name as the Owner -Builder.
We will not issue a building permit until you have read, initialed your understanding of each
provision, signed, and returned this form to us at our official address indicated. An agent of the
owner cannot execute this notice unless you, the property owner, obtain the prior approval of the
permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
60/ 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an
"Owner -Builder" building permit that erroneously implies that the property owner is providing his or her
own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious
financial risk for any injuries sustained by an unlicensed person and his or her employees while working
on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully
acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
7on r17y property.
2. 1 understand building permits are not required to be signed by property owners unless they are
1re onsible for the construction and are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I
understand that l may protect myself from potential financial risk by hiring a licensed Contractor and
h'ng the permit filed in his or her name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list
tr�license numbers on permits and contracts.
1t V 5. I understand if I employ or otherwise engage any persons, other than California licensed
F6rEctors,ad thetotal value of my construction is at least five hundred dollars ($500), including labor
aterials.1may be considered an "employer' under state and federal law.
. 1 understand if I am considered an "employer" under state and federal law, I must register with the
state and federal government, withhold payroll taxes, provide workers' compensation disability insurance,
and contribute to unemployment compensation for each "employee." I also understand my failure to abide
b h se laws may subject me to serious financial risk.
Ji7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds
ngle -family residential structures cannot legally build them with the intent to offer them for sale, unless
all work is performed by licensed subcontractors and the number of structures does not exceed four
within any calendar year, or all of the work is performed under contract with a licensed general building
Co rector.
8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be
he d liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any
latent construction defects in the workmanship or materials.
Forms\owner builder verifdoc 08/12/16 1 Oft
9. 1 understand I may obtain more information regarding my, obligations as an "employer'.from _the
I ternal Revenue Service, the United States Small Business Administration, the California Department of
' Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the
California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for
• mode information about licensed contractors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and
understand that I am the partlegally and flnanci Iy responsi IIg for propose con truction activity at the
foli ing address: 5- f'0 S e <G(A � L W I �P�.v�rt.� j�jCux.�,
11. 1 agree that, as the party legally and financially responsible for this proposed construction
a ivity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as
employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to
Of the information I have provided on this form.
Licensed contractors are regulated by laws designed to protect the public. If you contract with someone
who does not have a license, the Contractors' State License Board may be unable to assist you with any
financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor
or employee of that individual or firm is injured while working on your property, you may be held liable for
damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible
for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property
owner and returned to the City of Newport Beach, Building Division, for issuing the permit.
Note: A copy of the property owner's driver's license or form notarization is required to be
presented when the permit is issued to verify the property owner's signature.
Print name of property owner:
Property Owner's Signature: a/ A Date: 7/c/(.Y
Note: The following Authorization Form is required to be completed by the property owner only
when designating an agent of the property owner to apply for a construction permit for the
Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal
responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file
the documents necessary to obtain an Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
- Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I
personally filled out the above information and certify its accuracy. Note: A copy of the owner's drivers
license, form notarization, or other verification acceptable to the agency is required to be presented when
the permit is issued to verify the property owner's signature.
Property Owner's Signature:
Date:
Note: A copy of the owner's driver's license or form notarization is required to be presented when the
permit is issued to verify the property owner's signature.
Pormslow er builder veri£doc 08/12/16 2 oft
a
CITE' OF NE P 'I' BEACH
s;:f)111iMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive ( P.0: Box 1768 1 Newport Beach, CA 92658-8915
wwvd newp rtbeactj:,a,Ky I (949) 644-3200
i Prole Yh�idress`
Report Date:
CNB Inspector Name
ONB Pr� it#:
Bm ding 2ver Name'
OfFull
Owner's Mailing Address {if different: from site)
Owners Telephone #:
CNB Plan Check #;
gName ofpS��tggructui�al Observer ISO):
{�+���L" V4 lT a _V
$0 E-mail Addressssp�p+ J�'y
I(/6 v"� tl ��+•d +7�:`
(S�O�}Tdaeileephone ib;
f.! C �r�I%".(.
So License Reg. #:
PLEASE INDlCATF ATnIBCTIInAI F1 Fldl rh'rC area rnMMCr`T1nK1C n0e=011=n
FOUNDATIONS
SHEAR WALKS
FRAMES
DIAPHRAGMS
{FtocrrlRdot}.,
INDICATE LOCATION(5) DATE
OBSERVED OBSERVED
Ll Conventional
Footings &Slab s.
❑ Concrete
❑ Steel
❑ Concrete'
O Mat Foundation,
:Prestressed Concrete
❑ Masonry
El Concrete
D Steel Deck
E1 Caissons, Piles, El Wood 'crManuf Cl Masonry t�/Wood
Grade Beams _ Shear Panels _✓�
O Other: ❑ Other: 0 Other: f 1_11 Other;:.
CI ITEMS CHECKED ABOVE ARE: APPROVED AND WITHOUT DEFICIENCIES.
❑ (OBSERVED DEFICIENCIES AND COMMENTS:
r
❑ REPORT CONTINUED ON ATTACH ED. PAGES.
❑ FINAL STRUCTURAL OBSERVATION REPORT:
The structure q2nerally complies with the appravetl construction documents,. and all observed deficiencies were corrected.
--`----
I declare that the following statements are true to the best of my knowledge:
1. 1 amthelicensed'desi
charge of the structural
2. 1, or another licensed de
my responsible charge,
construction stage to v
approved construction
3. l understand that all def
final acceptance. of the
Division.
&inmVSmVailndebanv..itioiiitenan3Lisonedon%
retained by the owner to be in responsible
I whom 1 have designated above and is under
J the required site visits at each significant
ructUre is In general confoimance with the
I have documented must be corrected, prior to
ams by the City of Newport Beach, Building
FOR BUILDING INSPECTION BY AUTHORIZED EMPLOYEES OF THF CITYnF NFwanaT RnnrM
e
I
a6��PV/Y.
CITY OF NEWPORT BEACH
`°h $ COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www.newportbeachea.00v 1(949)644-3200
Structural Observation Report
Pro" ct a s:
Report Date: A �r Iq
CNB Inspector Name:
CNB Permit#:
Buil&g g Owner Name:
Owners Mailing Address (if different from site);
Owner's Telephone #:
CNB Plan Check #:
Full��f S ctwal Observer (SO):
T✓V C/7rAsliO' Ual.i
SO E-mail Address: r� l/nh P
/f1�`9 idv/'t/!.J /�1.�111 rY1NO'../Y
SO�elephone #:
_fill ql V✓/i1,rp_9?
$p License /Reg. N:
0 17
PLEASE INDICATE STRUCTURAL ELEMENTS AND CONNECTIONS ORSFRVFn rchne4 annlrrehtn h--%
FOUNDATIONS
SHEAR WALLS
FRAMES
DIAPHRAGMS
(Floor/Roof)
INDICATE LOCATION(S) V
OBSERVED
DATE
OBSERVED
❑ Conventional
Footings & Slab
❑ Concrete
❑ Steel
❑ Concrete
❑ Mat Foundation,
Prestressed Concrete
❑ Masonry
❑ Concrete
❑ Steel Deck
❑ Caissons, Piles,
Grade Beams le
Wood or Manuf..
Shear Panels
❑ Masonry
❑ Wood
❑ Other:
❑ Other:
❑ Other:
❑ Other:
A/,,'/
ITEMS CHECKED ABOVE ARE APPROVED AND WITHOUT DEFICIENCIES.
❑ OBSERVED DEFICIENCIES AND COMMENTS:
n REPORT CONTINUED ON ATTACHED PAGES.
FINAL STRUCTURAL OBSERVATION REPORT:
The structure generally complies with the approved construction documents, and all observed deficiencies were corrected.
I declare that the following statements are true to the best of my knowledge:
1. I am the licensed design professional retained by the owner to be in responsible
charge of the structural observation;
2. I, or another licensed design professional whom I have designated above and is under
my responsible charge, have performed the required site visits at each significant
construction stage to verify that the structure is in general conformance with the
approved construction documents;
3. 1 understand that all deficiencies which I have documented must be corrected, prior to
final acceptance of the structural sysAems by the City of Newport Beach, Building
�q. n
n 39 in
n
\ M
b
Sp S�UCTU�P
STAMP OF STRI'T RAL OBSERVER
STRUCTURAL OSSERVAJION DOES NOT WAIVE ANY REQUIREMENTS FOR BUILDING INSPECTION BY AUTHORIZED EMPLOYEES OF THE CITY of NEWPORT RFncH.
15
CITY OF NEWPORTBEACH
BUILDING MV'ISION
100 Civic Centra Drive I P.O. Box 17613 1 Newport Beach, CA 92658-8915
rrtpv�r c :ov
1(949)644-3200
Structural Observation
Report
, CNin
eport Date' ctcrNane:�
I U ((d 1
Omer'S rtalln Afldraae rif d4terent Lam ci ^—
9 •)• i_?Ji3awr'a Telenhone'77.
GN13 Pem;q N:
Plan rhecR #:
Fm; Num of Ynaclwai t t .,U Ed dor ss _ - r m 1 =n I �e n ,a Raq 1C
a•, *n ua � s,+-
i r r iso) fat�6 tali._
PLEASE INDICATE STRUCTURAL ELEMENTS ANn rnNNPrTV)lJg nRQPPI1Pn rrc,o..r, ..,..r;....u,,.r.,........
FOUNDATIONS
SHEAR. WALLS
r FRAMES � DPAPHRAGMS � INDICATE LOCATIONS)
(Floorlftoof) OBSERVED
DATE
OBSERVED
D Conventional
_
COnc: ke+
Steel j !7 Can",'te - .. ."._
f00'Ungs &Slab
i
1 1
I ; Mot Foundation
a Masonry
(
+ u Concrete. L Sleet fleck
P+ slrassed Concrete
� j
,
L., Grasse s Poles,
Grade Beams
1 V\(rador —Min—t4_7
D Masonry •'WX ood i
• %
r rl Otttpr r
Shear Panels
Otlrel.
f
I i Uther { 1 Other. l
k
ITEistS CHECKED ABOVE ARE APPROVED AND WITHOUT DEFICIENCIES.
❑ OBSERVED DEFICIENCIES AND COMMENTS:
CI REPORT CONTINUED ON ATTACHED PAGES.
❑ FINAL STRUCTURAL OBSERVATION REPORT:
. TThe structure enei^tlly aoinlAles with the approved construction documents, and all observed defiiciencies were corrected.
hest__ 9 _ � __.
! daeia�,; C�ai i7 u, loilaw^ng xh+Eerm its ,.re %rue r� .;,� best of rr y kngwfen3a, — -- ._ _
?. I ani the hr.ensed design profe%monal retained by the owner to he in responsible
chsr�te of the staimural observation;
E. I, or another licensed deign prdfr clonal wham i have do vgnated above and is under
my responsible rharge have rer'ormed Ili rPquiretl sitc vi,its atatlt siynifie;ant
non tnreuon .,iaije to verify that Ilia ykucture is in general Conformance With the
approved cons ruci doeunr u nts X
I u Ido , 3na th 1 all ,.. fir,is.nt J- NfliM I !love ,or r!Ptri must be Corrected, prior to
final ecceplancj of the structural sYstflnlo by 111tA Cily of Newport Boach, Building \' ST UCTtd�Py `s3
Divis,on.
�Ot=cAf�fOf
G1 dP OF ST LICTLRAL OBSERVER
$"RtlCTURAi OBSERVATI DOE.si NOT IYAJIVE ANY PEUUI?Ek1ENTS FOR BUILDING INLaEOTl0N 9Y AM HORIZED EVT OYEEES OF 1 *1E CITY OF NE; PC PT SEACli.
num.. ,...,,,, .� r_. mmn.n•.
c1L� POztT
�4 m CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Box 1768 1 Newport Beach, CA 92658-8915
www,newoortbeachca aov 1 (949) 644-3200
Structural Observation Report
Projec ss:_ ,�,r _ -,
rNr
Report Date: , p
CNB Inspector Name:
CNB Permit #:
Building Own Name:
Owners Mailing Address (if different tram sile);
Owners Telephone #:
CNB Plan Check #:
Full Name of Structural Observer (SO):
�cffAi'L G A/M-
SO E-mail Address:
hf r hnh
SO Telephone #:
�1�`1 G9��
SO License / Reg. M
0�?-?�q
PLEASE INDICATE STRUCTURAL ELEMENTS AND CONNECTIONS OBSFRVFn leheek anniienhtn hnveei
FOUNDATIONS
SHEAR WALLS
FRAMES
DIAPHRAGMS
(Floor/Roof)
INDICATE LOCATION(S)
OBSERVED
DATE
❑ Conventional
Footings & Slab
❑ Concrete
❑ Steel
❑ Concrete
_OBSERVED
❑ Mat Foundation,
Prestressed. Concrete
❑ Masonry
❑ Concrete
❑ Steel Deck
71Caissons, Piles,
Grade Beams
ClWood or Manuf.
Shear Panels
ElMasonry
❑ Wood
J
❑ Other:
❑ Other:
❑Other:
❑ Other:
ITEMS CHECKED ABOVE ARE APPROVED AND WITHOUT DEFICIENCIES.
❑ OBSERVED DEFICIENCIES AND COMMENTS:
❑ REPORT CONTINUED ON ATTACHED PAGES.
❑ FINAL STRUCTURAL OBSERVATION REPORT:
The structure generally complies with thea proved construction documents, and all observed deficiencies were corrected.
I declare that the following statements are true to the best of my knowledge:
1. I am the licensed design professional retained by the owner to be in responsible
charge of the structural observation;
2. I, or another licensed design professional whom I have designated above and is under
my responsible charge, have performed the required site visits at each significant
construction stage to verify that the structure is in general conformance with the
approved construction documents;
3. 1 understand that all deficiencies which 1 have documented must be corrected, prior to
final acceptance of the structural systems by the City of Newport Beach, Building
Division; — , . f I
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NOT WAIVE ANY REQUIREMENTS FOR BUILDING INSPECTION BY AUTHORIZED EMPLOYEES OF THE CRY OF NEWPORT BEACH
1
CITY OF NEWPORT BEACH
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
100 Civic Center Drive I P.O. Boz 1768,1 Newport Beach, CA 92658-8915
www.newportbeachca.goV 1 (949) 644-3200
BUILDING HEIGHT CERTIFICATION
Project Street Address: , -Y03 5c*�#Vi!6
Building Permit Number(s):
As the surveyor of record for the project at the above address, I hereby certify that I have reviewed the
City of Newport Beach approved plan and original topographic survey and based the elevations listed
below on those plans.
Elevations shall include an allowance for roofing material thickness if not yet installed. Provide
each critical ridge and flat roof, or roof deck railing elevations indicated on the approved plans.
Use the format below on the back of this form if additional space is necessary or further
explanation is needed. Provide original copy to the inspector before roof framing inspection.
All elevation points are based on: j NAVD88 O NGVD29 O Assumed
Please provide the following elevation information for the highest roof ridges, flat roofs, or
parapets/guardrails. Additional elevation points may be requested by the Building Inspector
&ODWD 4" 77tie - 1010F.
RIDGES (3:12 slope or greater)
1. Approved elevation point of ridge is 411 Y and actual elevation point is
2. Approved elevation point of ridge is and actual elevation point is
3. Approved elevation point of ridge is and actual elevation point is
FLAT ROOFS,PPARAPETS AND GUARDRAILS
1. Approved elevation point of flat -roof or pZ"araflet is '31 and actual elevation point is %43. %b p -A-
2. Approved elevation point of flat roof or parapet is and actual elevation point is y- off 2a L
3. Approved elevation point of flat roof or parapet is and actual elevation point is
I certify that the above height measurements are correct and the above project:
IS in compliance with the City -approved plans.
OIS NOT in compliance with the City -approved plans (Provide explanation)
Please describe any deviation from the City -approved plans on the back of this form.
/0
Surveyor or Civil Engineer's*'signature and seal
(Wet stamp and signafure.required)
* License number of 33965 or lower
Forms\Building Height Certification 11/02/16
Date